Key expressions of trauma-related distress in Cambodian children: A step toward culturally sensitive trauma assessment and intervention

Abstract

More than half of all children in Cambodia experience direct abuse and over 70% experience other traumatic events, which significantly increase their risks for a range of physical and mental health problems. Additionally, Cambodian children face longstanding sociopolitical, intergenerational, and cultural factors that compound the impact of other trauma. As a result, rates of posttraumatic stress symptoms among Cambodian youth are high. However, care providers often rely on Western-based nosology that does not account for culturally specific expressions of trauma. A greater understanding of culturally-salient expressions of distress can help inform diagnostic assessment accuracy and treatment effectiveness and monitoring. The current study utilized a qualitative design to interview 30 Cambodian caregivers of children with trauma experiences and 30 Cambodian children (ages 10–13 years) with trauma experiences to identify key local expressions of trauma. Findings reveal certain PTSD symptoms and culturally-specific frequent and severe trauma-related problems for Cambodian children and domains of functioning impacted by trauma. Certain symptoms seem particularly important to evaluate in this group, such as anger, physical complaints (e.g., headache and palpitations), and cognitive-focused complaints (in particular, “thinking too much”). All caregivers and children reported physical health as impacted by trauma-related problems, highlighting a particularly salient domain of functioning for this population. Expressions of distress explored in the current study are discussed in the context of assessment and intervention development to inform diagnostic and clinical efforts for those working with trauma-exposed Cambodian children.

Keywords

Cambodia children idioms of distress global mental health posttraumatic stress trauma

Introduction

The impact of child trauma and trauma-related stress is particularly problematic in contexts with high rates of traumatization following war and genocide, such as in Cambodia. Children in Cambodia continue to face disproportionate rates of traumatic experiences and posttraumatic stress, with estimates of over 70% having experienced a traumatic life event (Schunert, 2012). In a study of 2,376 Cambodians conducted by UNICEF Cambodia (Ministry of Women’s Affairs, 2013), over half experienced physical violence before the age of 18 (52.7% for females, 54.2% for males), with over 80% of those with experiences of physical violence reporting multiple incidents. Family violence is also common. In 2000, 25% of women had been victims of emotional, physical, and/or sexual abuse from their husbands, which is likely an underestimate given underreporting (McCue, 2008). Caregivers and their children in Cambodia are also likely to encounter community violence. In the late 1990s, violent crime reached its peak in Cambodia, with a homicide rate of 11.6 in every 100,000 persons, the highest rate in the region, and second worldwide only to the Philippines (Broadhurst, 2002). For children born after the 1990s, community violence remains high and is linked to a range of maladaptive outcomes in children and youth, including depression (Yi et al., 2013) and risky sexual behavior (Yi et al., 2010).

Trauma experiences predict later detrimental psychological, behavioral, academic, social, and health outcomes among Cambodian youth (Kinseth, 2009; Schunert, 2012), with significant economic burden: the health consequences of childhood abuse totalled $186 million for Cambodia in 2013 (UNICEF, 2015). High rates of trauma exposure among Cambodian children are likely a result of multiple interactive processes, including family and social problems stemming from the “lost generation” of individuals in key positions to restore and reconstruct Cambodia’s spiritual, educational, and economic losses following the Khmer Rouge regime (e.g., doctors, teachers, spiritual leaders), transmission of acceptability of violence perpetration, and eroded social, health, and education systems. However, key posttraumatic stress symptoms of Cambodian youth are still relatively unknown. Currently, international and domestic service providers rely on posttraumatic stress symptoms derived from research with Western samples, which may not be representative of local experiences of distress following traumatic experiences.

Despite its common use across various geographical regions, including Cambodia (Cardozo, Kaiser, Gotway, & Agani, 2003; Cardozo, Talley, Burton, & Crawford, 2004; Cardozo, Vergara, Agani, & Gotway, 2000; Thienkrua et al., 2006), trauma and posttraumatic distress criteria shaped by political, legal, economic, social, and medical influences specific to Western contexts may not be ideal for measuring and targeting symptoms in efforts to alleviate distress (for a more in-depth history of the evolution of PTSD in Western culture, see Hinton & Good, 2016; Pitman, 2013). Additionally, numerous and complex stressors are associated with a range of symptoms and diagnoses with distinct and overlapping symptoms with PTSD criteria, including other internalizing (e.g., anxiety, depression; Rayburn, McWey, & Cui, 2016) and externalizing symptoms (e.g., aggression, defiance; Carliner, Gary, McLaughlin, & Keyes, 2017) among other diagnoses (e.g., functional somatic disorders; Afari et al., 2014). The intersection of direct trauma exposure, widespread societal violence, poverty, and erosion of health and education systems that are sequelae of the Khmer Rouge regime, coincide to shape the experiences of caregivers in modern Cambodia. Children and youth now living in Cambodia, born in the 2000s, are faced with continued direct violence exposure and limited access to education and health services compounded by secondary exposure to parental traumatization (De Walque, 2006; Lambert, Holzer, & Hasbun, 2014), Together, the trauma context of modern day Cambodia poses a particular difficulty for international trauma and posttraumatic stress researchers, as these young people’s posttraumatic reactions may not conform to conventional conceptualizations of trauma-related and other associated disorders (Kinseth, 2009).

Accordingly, Kleinman (1988) used the notion of a “categorical fallacy,” in which because a phenomenon can be identified across multiple cultural settings, it is assumed that it means the same thing in both contexts. Hinton and Good (2016) refer to researchers who do not assess all the symptoms related to a disorder, neglecting other locally salient complaints, like somatic symptoms, as “category truncation.” Of significant concern in cross-cultural assessments of distress and psychological treatments is the lack of universal, synonymous terms across contexts (Keys, Kaiser, Kohrt, Khoury, & Brewster, 2012). These culturally meaningful, shared experiences rooted in local concepts of health and illness, or “idioms of distress,” provide linguistically marked, culturally-salient symptomatology that expresses distress in locally intelligible terms (Kirmayer & Young, 1998). The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) defines cultural idioms of distress as “ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns.”

Assessing key local expressions of distress provides many types of clinical utility (for a review, see Hinton & Good, 2016). Cultural expressions of distress may indicate risk for destructive behavior (e.g., physical aggression and suicidality; Lopez & Guarnaccia, 2000), health-related concerns (Lewis-Fernández, Guarnaccia, Patel, Lizardi, & Diaz, 2005), poor psychosocial functioning (Lewis-Fernández, Guarnaccia, & Ruiz, 2009), past exposure to trauma (Hinton & Lewis-Fernández, 2010), and may themselves be a source of distress (Hinton, Hofmann, Pitman, Pollack, & Barlow, 2008; Hinton & Good, 2009). Further, the examination of expressions of distress helps illuminate barriers to accurate prevalence assessments and effective client–provider communication (Keys et al., 2012), and thus holds significant clinical relevance. Identifying local constructs of trauma and trauma-related stress allows healing professionals to identify those recognized as needing support and to appropriately employ existing local healing practices and other culturally-appropriate therapeutic interventions (Kohrt & Hruschka, 2010; Hinton & Lewis-Fernández, 2010).

In Cambodia, health and behavior are nested within a worldview of natural and ancestral spiritual forces that stress the importance of continuous life cycles and the role of karma in reincarnation (Van de Put & Eisenbruch, 2004). Thus, Cambodians often rely on spiritual and religious leaders for physical and psychological ailments, including managing distress. Traditional healers, or “Kruu Khmer,” and Buddhist monks are the primary sources of treatment and healing for Cambodians with a wide range of ailments (Van de Put & Eisenbruch, 2004). Traditional healing systems are particularly utilized in rural child populations who are often at great distance from a health center (Yanagisawa, Mey, & Wakai, 2004). These ideals are further embedded in the Khmer medical cosmology of illness that focuses on the prevention, maintenance, and restoration of social, spiritual, and physical balance (Ovesen & Trankell, 2010). Accordingly, prior studies suggest somatic expressions of distress play a particularly important role in Cambodian distress expression. For example, Cambodians often attribute the experiences of arousal-reactive symptoms in anxiety-related psychological distress (e.g., heart palpitations, sweating, dizziness) to a “weak heart” (khsaoy beh doung; Hinton, Hinton, Um, Chea, & Sak, 2002). A fear of weakness in blood flow leads to catastrophic cognitions and somatization when experiencing anxiety-related sensations akin to panic-attack symptomatology (or wind attack; gaeut khyâl), and often leads to engagement in safety behaviors to improve blood flow throughout the body. Other idioms of distress identified in Cambodian culture include “thinking too much” (kit chraern; i.e., a rumination syndrome) and “broken courage” (Baksbat: i.e., fearfulness, submissiveness, and the feeling of being mute or deaf; Chhim, 2012, 2013; Hinton, Reis, & de Jong, 2015, 2016).

Measures have been developed to assess idioms of distress among Cambodian populations. Hinton, Hinton, Eng, and Choung (2012) developed the Cambodian Symptom and Syndrome Inventory (C-SSI). The measure includes Cambodia-specific expressions of distress, including “gaeut khyâl” (wind attack), “kit chraern” (thinking too much), and sleep paralysis (or in Cambodia, “khmaoch sangot” [a ghost pushing you down]). Hinton and colleagues (2012) found culture-bound symptom scores on the Cambodian C-SSI increased significantly across levels of PTSD severity, illustrating that a Cambodian who meets criteria for PTSD also has several other culturally salient somatic symptoms, namely, expressions of khyâl, dizziness, and bodily weakness. This measure highlights the integration of DSM criteria found across cultural contexts with Cambodia-specific distress expressions to provide a more comprehensive and accurate representation of distress in this population. However, as the C-SSI was designed specifically for Cambodian adult refugee populations, the measure may not represent the experience of posttraumatic stress for youth currently living in Cambodia.

A majority of youth in Cambodia experience violence and trauma, and the sequelae of these experiences constitute a potent risk factor for later maladaptation. The current state of trauma and associated symptom presentations assessment with Cambodian children relies on Western-based nosology that does not take into account culturally-specific symptoms, which leads to misidentification and underestimation of posttraumatic stress prevalence in Cambodian children (Chhim, 2012), and may hinder intervention acceptability and effectiveness. It is also vitally important to determine what are the most salient trauma-related symptoms, which may include typical PTSD symptoms, a range of symptoms characteristic of other trauma-related disorders (such as depression, anxiety, somatic disorders, etc.), as well as locally specific complaints (Hinton & Good, 2016). Culturally-salient symptoms identified in prior studies with Cambodian adult populations reviewed above provide guidance for expected variations in symptoms in a Cambodian child sample (e.g., a particular emphasis on somatic symptoms). However, notable differences are anticipated, including developmental variations and the impact of trauma-related problems on areas of daily functioning. Further, we expect somewhat discrepant caregiver- and child-reported problem frequency and severity. Accordingly, in a study of Cambodian adolescent refugees, youth reported more distress with school, their peers, and themselves than was reported by their caregivers (Sack, Angell, Kinzie, & Rath, 1986).

Accurate prevalence estimates of trauma are key as they inform the amount and type of foreign and domestic aid services directed toward child mental health (Summerfield, 2001), and treatments targeting PTSD-based symptoms may neglect salient experiences of distress in Cambodian children, which may lead to suboptimal treatment efficacy (Hinton & Otto, 2006) and low treatment adherence (Hinton & Lewis-Fernández, 2010). Interventions that target culturally-salient symptomatology show better effectiveness, patient adherence, and acceptability (Hinton & Lewis- Fernández, 2010).

Thus, the present study used qualitative interviews to evaluate child-level expressions of posttraumatic distress from the perspective of the youth affected and their caregivers. Data was obtained using the qualitative methods outlined in the Design, Implementation, Monitoring, and Evaluation of mental health and psychosocial assistance programs for trauma survivors in low resource countries – Module 1 (DIME; Applied Mental Health Research (AMHR Group, 2013). The DIME procedure is a method for assessing cultural expressions of distress for trauma survivors in low resource countries, and is designed to elicit linguistically-marked, ethnoculturally meaningful expressions of distress following trauma exposure.

This study was conducted in collaboration with the Transcultural Psychosocial Organization Cambodia (TPO). TPO Cambodia is a not-for-profit non-governmental organization (NGO) run and staffed by Cambodians. TPO operates across seven sites throughout Cambodia, and aims to improve the mental health of Cambodians with traumatic experiences and promote positive health policy change. Our research aims were to:

Identify expressions of distress in Cambodian children exposed to traumatic events, namely, domestic violence.

Identify the perceived severity of reported expressions of distress.

Identify areas of functioning (e.g., school, family relationships, etc.) impacted by reported expressions of distress.

A key step towards culturally sensitive trauma assessment and intervention design for Cambodian children is identifying local trauma-related problems, the perceived severity of these problems, and the areas of the child’s life impacted.

Methods

Participants

Participants were recruited in-person via TPO support staff from TPO Cambodia’s “Improving Mental Health for Survivors of Gender-Based Violence & Sexual Assault” community program in the rural Banan District of the Battambang province in northwest Cambodia. Rural populations constitute 85% of the total population of Cambodia (NIS, 2019). Participants were caregivers of children and children (age 10–13 years) who were receiving mental health services at TPO at the time of the interview to address exposure to domestic violence and other traumatic events. All children receiving support through this program were identified as affected by domestic violence, as either a witness or a survivor, and for a range of other potentially traumatic experiences. Trauma event details were not directly assessed in the current study, including the extent of perpetration and victimization of violence for both children and caregivers. Following completion of the caregiver interview, the interviewers obtained consent to request assent from child participants.

Procedure

In-person interviews were conducted with 30 children with trauma experiences and their 30 caregivers by two full-time mental health professionals employed by TPO, proficient in both the local language (Khmer) and English. The mental health professionals have extensive clinical experience (20+ years) in the community. Interviewers underwent interview administration training according to DIME procedures and Human Subjects Training, both led by the first author (CF). The first author attended the initial 5 interviews with both interviewers to guide and answer questions, and remained in close proximity for the remaining interviews. Further, the first author lived in the region of Cambodia for approximately 10 months, and engaged TPO as a consultant and a direct service provider. As compensation for participation, caregivers received $5 USD and children received school supplies and soap; compensation type and amount was decided upon in collaboration with TPO in efforts to ensure appropriateness and reduce coercion. Interviews were conducted in Khmer in private rooms of homes in the community used for TPO programming, and were audio-recorded. All study materials and procedures were approved by DePaul University’s Institutional Review Board. Informed consent was obtained for all participants. Both caregivers and children were asked the following questions; all responses are regarding child experiences and expressions:

“What are all the problems that affect children after seeing or experiencing things that are scary, dangerous or violent?”

“How would you rate the severity of this problem in children’s daily lives?”

“What areas of children’s lives are affected by this problem?”

The interviewer repeatedly prompted the interviewee for additional problems until the interviewee indicated that they had no further responses, up to 10 problems. Severity rankings were elicited on a 1–10 Likert scale (1 = Not at all a problem in the child’s daily life to 10 = Very much a problem in the child’s daily life).

Data analyses

Analyses were conducted according to DIME procedures (AMHR Group, 2013), which aim to extract identifiable, singular problems from interviewee responses, and aggregate summary sheets completed during the interviews into a final summary sheet with a frequency count of all problems listed across participants. This provides a final summary aggregate of problems, ranked by frequency and severity, to identify the most common and most severe trauma-related problems listed by participants.

Results

Demographics

Interviews were conducted with 30 youth and 30 caregivers of children identified as affected by family violence. Support staff reported children often experienced additional potentially traumatic stressors, but trauma experience was not systematically assessed in this study. Of 30 caregiver participants, 24 were female and 6 were male. Caregiver ages ranged from 30–62 years (M = 44.03 years, SD = 10.60); 28 were married and 2 widowed; and cared for between 1–11 children (M = 4.27, SD = 2.2). Of the 25 caregivers who had attended school, 22 completed primary school, 2 completed secondary school, and 1 attended college. Caregivers also reported on their abilities in reading (n = 15 “Can read”; n = 10 “Cannot read”; and n = 5 “Can read somewhat”) and writing (n = 14 “Can write”; n = 12 “Cannot write”; and n = 4 “Can write somewhat”). Among adult participants there were 12 farmers, 9 skilled laborers, 4 vendors, 3 housewives, and 2 unskilled laborers. Although rural, the sociodemographic characteristics of the current sample are comparable to nationally representative samples, given the high proportion of rural populations in Cambodia (e.g., Seponski, Lahar, Khann, Kao, & Schunert, 2019).

Child participants included 14 males and 16 females. Child ages ranged from 10 years to 13 years, 5 months (M = 11.7 years, SD = 1.12). A range of 4 to 13 people were reported to live with the child (M = 6.23, SD = 2.18). Children also reported on who they perceived as their primary caregivers: 14 reported their biological parent(s), 6 their grandparent(s), 2 their aunt and/or uncle, and 8 reported all family members, including a combination of parents, grandparents, aunts/uncles, and siblings. All children attended schools in the Banan district.

Problem frequency, severity, and impact on functioning

Responses are presented here split by caregiver- and youth-report to highlight problems salient to each group respectively. Tables 1 and 2 are ranked by frequency of report, and also include severity ratings and the three most frequently reported areas of functioning impacted.

Table 1.

Caregiver-reported problems, ranked by frequency (N = 30).

Problem (transliteration)	Frequency %	Severity Mean (1–10)	Areas of functioning (% reported)
Easily angered Mour Mao	67	6.25	School (45) Cognitive (40)
Crying Yom	50	5.87	Physical (60) School (47)
Other physical ailments Chum-Gneu Reang Kai Phseng Teat	43	5.85	School (62) Daily work (23)
Sad face Moak Kriem	40	4.42	School (58) Cognitive (42)
Headache Chheur (Kbal) Kobal	40	6.08	School (42) Daily work (33)
Fearfulness Phay Klach	40	7.42	Physical (67) School (42)
Thinking too much Kit Chraern	40	5.67	Physical (58) School (25)
Difficulties w/ learning e.g., Rien Men Ches	40	5.50	School (33) TTM (25)
Poor sleep Dek Men Sov Lok	37	6.36	Physical (73) School (36)
Shame Kour Ouy Amas Nash	33	6.20	Cognitive (40) Family (30)
Worry Prouy Chroeun	33	6.50	School (60) Cognitive (50)
Isolation/Withdrawal Ek Ka/Dork Khloun Pi Ke Eng	23	5.20	Affective (40) School (30)
Difficulties w/school attendance Banha-Ha Ah Wata Mean	23	4.86	Affective (71) Friends (29)
Restlessness/Hyperactivity Ro-Sab Ro-sorl/Nov Min Sgniem	20	6.83	Cognitive (33) TTM (17)
Forgetfulness Phlech Phlaing	20	6.33	School (83) Family (50)
Rapid heart rate Beh-Dong Doeu Nyaob	13	8.00	Physical (75) School (50)
Verbal aggression Sam Dey Kach/Sam Dey Bampean	13	3.50	Physical (75) Affective (50)

Note. Only responses reported by > 3 interviewees included. TTM = Thinking Too Much

Table 2.

Youth-reported problems, ranked by frequency (N = 30).

Problem (transliteration)	Frequency %	Severity Mean (1–10)	Areas of functioning (% reported)
Easily angered Mour Mao	67	6.25	School (50) Physical (50)
Headache Chheur (Kbal) Kobal	57	5.94	School (59) Cognitive (47)
Fearfulness Phay Klach	57	6.47	Physical (47) School (35)
Rapid heart rate Beh-Dong Doeu Nyaob	50	6.33	School (53) Affective (27)
Crying Yom	50	6.53	Physical (42) School (33)
Shame Kour Ouy Amas Nash	47	6.64	School (71) Friends (43)
Other physical ailments Chum-Gneu Reang Kai Phseng Teat	47	5.21	School (57) Affective (50)
Worry Prouy Chroeun	43	6.08	School (77) Friends (46)
Thinking too much Kit Chraern	30	6.22	Physical (67) Cognitive (33)
Poor sleep Dek Men Sov Lok	30	8.00	Physical (67) Cognitive (33)
Isolation/Withdrawal Ek Ka	27	5.13	Cognitive (50) School (38)
Difficulty w/learning e.g., Rien Men Ches	23	7.57	Affective (100) Daily work (29)
Difficulties w/school attendance Banha-Ha Ah Wata Mean	23	7.14	Physical (43) Friends (43)
Problems w/peers Banha-Ha Jea Muy Met Pheak	23	4.29	School (43) Affective (29)
Fatigue/Exhaustion Ors Kam Lang	20	7.67	Daily work (50) School (50)
Sad face Moak Kriem	17	6.80	Friends (60) School (60)
Poor appetite Ort Khlean Aha (Ort Khlean Bay)	13	6.25	Physical (25) –

Note. Only responses reported by >3 interviewees included.

Table 3 displays problems ranked by frequency using the full sample (caregivers and youth), and also includes areas of functioning impacted. Table 4 displays caregiver- and youth-reported problems, ranked by severity. Table 5 displays examples of commonly reported areas of functioning for each domain (i.e., school, physical, affective, etc.), and the percentage of participants who reported the area of functioning was impacted by trauma-related stress symptoms.

Table 3.

Combined problems, ranked by frequency (N = 60).

Problem (transliteration)	Frequency %	Areas of functioning (% reported)
Easily angered Mour Mao	67	School (48) Physical (35)
Crying Yom	50	Physical (63) School (43)
Headache Chheur (Kbal) Kobal	48	School (52) Cognitive (34)
Fearfulness Phay Klach	48	Physical (55) School (38)
Other physical ailments Chum-Gneu Reang Kai Phseng Teat	45	School (59) Affective (37)
Shameful Kour Ouy Amas Nash	40	School (54) Friends (33)
Worry Prouy Chroeun	38	School (70) Physical (39)
Thinking too much Kit Chraern	35	Physical (62) School (24)
Poor sleep Dek Men Sov Lok	33	Physical (70) School (35)
Rapid heart rate Beh-Dong Doeu Nyaob	32	School (53) Daily Work (26)
Difficulty w/learning e.g., Rien Men Ches	32	School (47) Affective (42)
Isolation/Withdrawal Ek Ka/Dork Khloun Pi Ke Eng	30	Affective (39) School (39)
Sadness/Sad face Moak Kriem	23	School (59) Friends (35)
Difficulties w/school attendance Banha-Ha Ah Wata Mean	28	Affective (50) Friends (36)
Forgetfulness Phlech Phlaing	13	School (75) Family (38)
Problems with peers Banha-Ha Jea Muy Met Pheak	13	School (38) Affective (25)
Fatigue/Exhaustion Ors Kam Lang	13	School (50) Friends (50)

Note. Only responses reported by >6 interviewees included.

Table 4.

Caregiver- and child-reported problems, ranked by severity rating.

Caregiver-reported problem (transliteration)	Severity*	Child-reported problem (transliteration)	Severity*
Rapid heart rate Beh-Dong Doeu Nyaob	8.00	Poor sleep Dek Men Sov Lok	8.00
Fearfulness Phay Klach	7.42	Fatigue/Exhaustion Ors Kam Lang	7.67
Restlessness/Hyperactivity Ro-Sab Ro-sorl/Nov Min Sgniem	6.83	Difficulties w/ learning e.g., Rien Men Ches	7.57
Worry Prouy Chroeun	6.50	Difficulties w/ school attendance Banha-Ha Ah Wata Mean	7.14
Poor sleep Dek Men Sov Lok	6.36	Sadness/Sad face Moak Kriem	6.80
Forgetfulness Phlech Phlaing	6.33	Shameful Kour Ouy Amas Nash	6.64
Easily angered Mour Mao	6.25	Crying Yom	6.53
Shameful Kour Ouy Amas Nash	6.20	Fearfulness Phay Klach	6.47
Headache Chheur (Kbal) Kobal	6.08	Rapid heart rate Beh-Dong Doeu Nyaob	6.33
Crying Yom	5.87	Easily angered Mour Mao	6.25
Other physical ailments Chum-Gneu Reang Kai Phseng Teat	5.85	Poor appetite Ort Khlean Aha (Ort Khlean Bay)	6.25
Thinking too much Kit Chraern	5.67	Thinking too much Kit Chraern	6.22
Difficulties w/learning e.g., Rien Men Ches	5.50	Worry Prouy Chroeun	6.08
Isolation/Withdrawal Ek Ka/Dork Khloun Pi Ke Eng	5.20	Headache Chheur (Kbal) Kobal	5.94
Difficulties w/school attendance Banha-Ha Ah Wata Mean	4.86	Stomach ache Cheur Kro Pheah	5.25
Sad face Moak Kriem	4.42	Other physical ailments Chum-Gneu Reang Kai Phseng Teat	5.21
Verbal aggression Sam Dey Kach/Sam Dey Bampean	3.50	Isolation/Withdrawal Ek Ka/Dork Khloun Pi Ke Eng	5.13
–		Problems w/ peers Banha-Ha Jea Muy Met Pheak	4.29

Note. Only responses reported by >3 interviewees included.

Mean on 1–10 scale.

Table 5.

Areas of functioning impacted by posttraumatic stress.

Area of functioning	Caregivers (n = 30) %*	Children (n = 30) %*	Frequently-reported examples
Physical	97	100	Headache Trembling Difficulty breathing Dizziness	Health is weak Pale face Stunted growth Rapid heart rate
School	93	97	Poor concentration Doesn’t want to attend Poor comprehension	Decreased studying Poor grades Cannot follow lesson
Cognitive	87	87	“Difficulty thinking” Shameful “Doesn’t want to do anything” “Can’t remember” Hopelessness	“Cannot think deeply” Anxious Self-pity Anhedonia Perseveration
Affective	77	87	Upset Embarrassed Frightened	Bad temper/Angry Hiding from others to cry Blunted affect
Friends	63	83	Doesn’t want to engage peers Peers don’t want to play Isolation	Embarrassed due to shame Low quality friendships Frequent conflict with peers
Daily work	60	70	Low quality work Doesn’t want to do daily work	Forgetful of directions Defiance in completing work
Family	60	53	Poor communication w/ family Resistant to join family activities Anger toward caregivers	Conflict with siblings Conflict with caregivers Running away from home

Note. *Percentage of participants who reported the area of functioning was impacted by one or more posttraumatic problems.

Discussion

Findings of the current study highlight frequent and salient symptoms experienced by this sample of Cambodian youth with trauma experiences. Overall, the problems reported across caregivers and children identify symptoms across a range of domains of functioning, including physical, cognitive, affective, social, and occupational. This aligns with prior findings of Cambodian adolescent refugees (e.g., Kinzie, Sack, Angell, Manson, & Rath, 1986), which found posttraumatic stress and associated symptoms to impact multiple domains of functioning.

Both children and caregivers noted an emotion term, easily angered or mour mao, as the most frequent trauma-related problem for youth (67% of caregivers and children), which is also a symptom similarly outlined in the DSM-5 criteria for PTSD, Major Depressive Disorder, and other diagnoses as irritability. This symptom is also notable in its predictive power of later violent and aggressive behavior among adolescents and Cambodian adults in the US. One prior study of African American, White, and Hispanic students aged 14–19 in the United States found anger predicted violent behavior better than any other PTSD symptom (Song, Singer, & Anglin, 1998), which is in keeping with other studies that show emotional regulation capacities are a robust predictor of later violence (Caiozzo, Houston, & Grych, 2016). In a study of adult Cambodian refugees in the United States (Hinton, Rasmussen, Nou, Pollack, & Good, 2009) anger expression was both a strong indicator of PTSD (i.e., 66% of participants with an anger episode in the last month met PTSD criteria, where only 33% of those without PTSD had an anger episode in the last month) and often activated physiological arousal akin to panic attack symptomatology. Hinton and colleagues (2009) call for further examination of intergenerational transmission of anger as an important aspect of trauma and PTSD in Cambodian populations. The current study, while not directly examining intergenerational transmission of anger, suggests anger is an important expression of distress in Cambodian family systems affected by trauma.

Other prominent emotion terms included sad face or moak kriem (40% of caregivers, 17% of children) and fearfulness or phay klach (57% of children, 40% of caregivers). Fearfulness was rated as the second most severe problem according to caregivers and reported to most frequently impact physical health and school success, indicating an emotion symptom that is salient to caregivers and may particularly interfere with daily functioning for trauma-affected Cambodian children.

Many symptoms noted, however, are not in the DSM-5 criteria for PTSD. For example, physical symptoms, which Hinton and Lewis-Fernández (2010, 2011) suggest may be prominent in many cultural groups as a result of trauma. Palpitations or beh-dong doeu nyaob was a frequent complaint, particularly for children (50% of children), and was rated as the most severe child problem by caregivers (M = 8.00). For Cambodians, physical symptoms are considered increasingly concerning the closer they occur to the chest, often leading to catastrophic cognitions (e.g., heart attack, cardiac arrest, or a weak heart; e.g., Hinton et al., 2002). Hence, certain culturally-salient healing practices, such as coining, are intended to direct blood flow away from the torso. Other somatic symptoms endorsed by both caregivers and children, included headaches or chheur (kbal) kobal (40% of caregivers, 57% of children), and other physical ailments or chum-gneu reang kai phseng teat (43% of caregivers, 47% of children), a category created to capture physical symptoms with fewer than three endorsements. This category includes, but is not limited to: poor appetite, nausea, difficulty breathing, dizziness, “severe illness,” coughing, “weak health,” hot face, eyes, and body, convulsions, “pale face,” stunted growth, and fever. The high rate and severity of somatic symptom reporting is notable in its contrast to DSM- and ICD-based PTSD nosology, which tend to primarily capture cognitive and affective symptom presentations. However, somatic symptoms are outlined in other DSM-5 disorder criteria, such as Somatic Symptom Disorder, highlighting the cross-diagnostic nature of distress expression in this population that may not be captured by a single, PTSD symptom assessment.

A range of cognitive-focused symptoms were reported by children and caregivers, including shame or kour ouy amas nash (33% of caregivers, 47% of children), worry or prouy chroeun (33% of caregivers, 43% of children), forgetfulness or phlech phlaing (20% of caregivers), and school difficulties in learning and comprehension (e.g., rien men ches; 40% of caregivers, 23% of children). Shame, in the context of culturally pertinent collective values (such as saving face), may be compounded with stigma surrounding mental health illness to decrease the likelihood of a child (a) reporting that difficulties are psychological in nature and (b) engaging in help-seeking behavior (Chang & Subramaniam, 2008). Accordingly, fear of losing face has predicted less help-seeking behavior in Asian populations (e.g., Zane & Yeh, 2002). Forgetfulness has been identified among adult traumatized Cambodians as a prominent trauma symptom, and that it is often attributed to excessive worry and rumination, which are often part of the “thinking too much” syndrome (Hinton et al., 2015, 2016).

Thinking too much (TTM), or thinking a lot, has been identified as a key idiom of distress in many cultural contexts (for a review, see Kaiser et al., 2014) insofar as to be included as an entry in the glossary of cultural concepts of distress in the DSM-5 (American Psychiatric Association, 2013). In the current sample, 40% of caregivers and 30% of children reported TTM as a trauma-related problem, respectively. TTM is considered to be akin to rumination in a broad sense; an inability to shift attentional focus and distance oneself from past hardship (Hinton et al., 2015). This rumination both causes and perpetuates multiple forms of distress (e.g., insomnia, somatic distress, irritability, among others) that lead to exacerbated PTSD symptoms (Kaiser et al., 2014). The presence of TTM has been found to be one of the best indicators of PTSD in adult Cambodian refugee populations, with high correlations to reductions in posttraumatic stress during and following treatment (Hinton et al., 2012). In the current study, 12 caregivers and 9 youth reported TTM as a problem associated with traumatic experience (40% and 30%, respectively), which aligns with and extends prior findings of TTM in adult Cambodian refugee samples to children still residing in Cambodia.

Furthermore, TTM was not only reported as a trauma-related problem, but also an area of functioning impacted by posttraumatic symptoms and a cause of other symptoms, suggesting bidirectional influences between TTM and symptoms associated with traumatic experiences. A recent meta-analytic review of the TTM idiom across cultural contexts revealed TTM has been reported as a symptom, a syndrome, and a cause (Kaiser et al., 2014). This aligns with a recent model proposed by Hinton and colleagues (2015, 2016) of the interrelationships of TTM, associated distress (specifically, insomnia, catastrophic cognitions, somatic distress, negative memory, and irritability), and PTSD symptoms. Accordingly, in the current study, TTM was mentioned as an area of impairment associated with poor sleep, headaches/trembling/chest pain/fatigue, forgetfulness, worry/fearfulness, and “mour mao,” among others. Together, our findings support the notion that for Cambodians, TTM is central to the trauma ontology and the construct validity of instruments that assess posttraumatic stress (Hinton et al., 2015, 2016; on content validity, see Hinton & Lewis-Fernández , 2011). “Thinking a lot” would seem to be at the center of causal networks, triggering multiple symptoms, and hence a key treatment target.

Behavioral complaints were also reported, including crying or yom (50% of caregivers and children), isolation/withdrawal or ek ka/dork khloun pi ke eng (23% of caregivers, 27% of children), school attendance difficulties or banha-ha ah wata mean (23% of caregivers and children), restlessness/hyperactivity or ro-sab ro-sorl/nov min sgniem (20% of caregivers) and verbal aggression or sam dey kach/sam dey bampean (13% of caregivers). Of the reported behavioral problems, restlessness/hyperactivity was rated one of the most severe problems by caregivers (M = 6.83) and difficulties with school attendance was rated one of the most severe problems by children (M = 7.14), indicating these problems as particularly troublesome for caregivers and children, respectively. Behavioral problems were reported to interfere with the children’s physical health, cognitive functioning, and peer relationships.

For children, poor sleep, fatigue/exhaustion, and difficulties with school were rated as the most severe problems. While other problems were reported as occurring more frequently, these severity ratings provide insight into a child’s experience of posttraumatic stress and the domains of functioning considered most salient. Prior studies have demonstrated that depletion of bodily energy is of particular concern to Cambodian populations, as bodily weakness may predispose youth to more severe symptomatology (Hinton et al., 2012). Further, poor sleep may perpetuate fatigue and difficulties with school comprehension/attendance, reflecting a cluster of symptoms and functional impairment highly salient to Cambodian youth in this sample.

Areas of functioning impacted provide insight into the effects of trauma-related symptomatology on domains pertinent to a child’s daily life. These findings suggest trauma-related problems in Cambodian youth in this sample are perceived to interfere with a child’s school functioning (including comprehension, attendance, motivation to study, and concentration) and a variety of physical ailments (including headache, trembling, weak health, pale face, dizziness, and stunted growth, among others), as well as cognitive and affective domains, interference with peer and family relationships, ability to complete daily work tasks, and “thinking too much.” The onset of marked problems in these domains may warrant further exploration of traumatic experience and trauma-related stress in Cambodian children.

The area of functioning most frequently reported as impacted by trauma-related distress in the current sample was physical functioning, which indicates physical functioning is both frequently impacted by posttraumatic stress and a domain in which Cambodian families are particularly sensitive to perceived impairment. Examples of physical health consequences of distress reported in the current study highlight a wide range of ailments that caregivers and children attribute to posttraumatic distress, including common ailments such as headache, stomach ache, and difficulty sleeping to less common ailments, such as “kren” (or stunted growth), nose bleeds, convulsions, and pale face, to those akin to panic attack, or “gaeut khyâl” (wind attack) symptomatology, such as rapid heart rate, difficulty breathing, and dizziness. Particularly in samples with typically high rates of malnourishment and illness, the psychological vs. physical root of somatic ailments may be difficult to disentangle, if even possible, as they often perpetuate each other (Van Schaack, Reicherter, & Chhang, 2011), particularly in health belief systems that do not dichotomize mind and body, such as Cambodia (Chung & Singer, 1995). More importantly, however, the current findings identify physical ailment attributions that caregivers and children tie to their traumatic experiences, which is applicable to clinical assessment, targets for treatment, reasons for service-seeking, and subsequent perceptions of treatment appropriateness and effectiveness. Stressor-related somatic symptoms are not unique to Cambodian children and found in other populations (Javanbakht, Rosenberg, Haddad, & Arfken, 2018), further supporting the integration of somatic symptoms as an important sequela of life stress across contexts. Further, the consistency in which all problem types (emotion, somatic, cognitive, and behavioral) were reported to impact physical health outcomes may also suggest that often only symptoms perceived to impact physical domains were considered sufficiently worrisome to report as trauma-related problems in children.

School attendance and academic success was also frequently reported as an area of functioning impacted by trauma-related problems. Studies of education systems in Cambodia show consistent and substantial community participation in school system modernization efforts following the Khmer Rouge regime (e.g., Bredenberg & Dahal, 2000). However, access to formal education is still limited, and is often exclusively available to those with the financial means to pay for school on a daily basis (Filmer & Schady, 2008), adding considerable barriers to education access and success. The current findings suggest trauma-related psychological distress may pose an additional barrier to school access and success. Addressing Cambodian children’s expressions of distress may contribute to their capability to attend school and better comprehend the material. Further, considering school access and success a pertinent target for intervention in trauma-affected Cambodian children will promote a domain of functioning salient to Cambodian families, and likely increase the acceptability and perceived effectiveness of the intervention efforts.

Cognitive and affective domains, friend and family relationships, and daily work were also reported to be impacted by posttraumatic stress in the current sample. Impairment across a child’s areas of functioning suggests both the assessment and treatment of child trauma in Cambodia should target domains across the child’s social ecological levels, including family, peer, academic, religious/spiritual, and community functioning. Additionally, future studies should examine how symptoms and social ecological domains of impaired functioning reported in this study are associated with psychiatric symptom presentations (e.g., Hinton et al., 2015) to inform assessment/intervention adaptation and development (e.g., Hinton et al., 2012; Kohrt et al., 2011). Further, although numerous areas of functioning were reported as impaired by posttraumatic stress, it is important to consider areas of resilience and growth following adverse life experiences. Previous studies of resilience demonstrate most children with trauma experiences do not exhibit global impairment across domains, but instead exhibit resilience in some areas and impairment in others (e.g., Martinez-Torteya, Miller-Graff, Howell, & Figge, 2015). Recognizing areas of resilience in Cambodian children will allow clinicians to mobilize strengths and foster adaptive functioning (see strengths-based approaches to intervention, such as Padesky & Mooney, 2012).

Several limitations should be acknowledged. First, although the current sample of children have all experienced a potentially traumatic event(s), there was no assessment, thus no minimum required presentation of posttraumatic stress symptoms to participate in the study. Consequently, results of the study should be considered in the context of a sample with a range of posttraumatic stress symptomatology, likely ranging from subthreshold to meeting criteria for DSM-5 PTSD or other disorders associated with trauma experiences. Further, children in this sample shared a common potentially traumatic event type, domestic violence. Thus, posttraumatic problem responses may be somewhat limited to this trauma type; however, many of the children in this sample also experienced a range of potentially traumatic experiences above and beyond domestic violence. Second, the current sample was drawn from children receiving psychotherapeutic services via the collaborative organization. Thus, the current sample may be particularly familiar with psychological vernacular and have likely already been provided coping skills and resources. Third, all caregivers in the current sample were victims of intimate partner violence and had thus experienced trauma themselves, which may impact both the types of problems their children experienced and caregiver reporting of child-level symptoms. Further, as trauma details were not directly assessed, current results do not account for the extent of perpetration and victimization of children and caregivers. Generalization to full community samples should be done with caution. Fourth, although a strength of this study is that all procedures and aggregate analyses were conducted in the local language, any data and interpretation requiring translation may forego meaningful language- and culture-specific intricacies. To combat this, every step of study design, data collection, coding, analysis, and manuscript preparation was implemented with a continually reflexive process with native Cambodian research and clinical personnel at TPO Cambodia.

To conclude, Cambodian children and their caregivers are likely the most accurate and informative reporters of trauma-related problems in Cambodian children. Symptoms and problems reported encompass multiple domains of child functioning, identify frequent and severe problems, and highlight unique and theoretically overlapping symptoms compared to Western-based PTSD criteria often used in contexts such as Cambodia. Designing assessments and interventions for trauma-related stress in Cambodian children that are feasible, acceptable, and effective can be optimized from the incorporation and targeting of symptoms and problems identified in the current study. Findings suggest key expressions in this population align with prior findings in Cambodian refugee populations, including anger, somatic symptoms such as headache and palpitations, and cognitive problems, particularly “thinking too much.” Other symptoms identified are developmentally and contextually unique, such as difficulties with school attendance and learning and a range of physical ailments attributed to traumatic experiences. Accordingly, across all domains and almost 100% of participants, physical health functioning was reported as impacted by trauma-related problems. Areas of functioning reported in the current study also highlight a unique contribution to the existing body of literature on trauma-related problems in Cambodian populations, as they provide contextually-specific effects on functioning for children still residing in Cambodia. Considering these key expressions and physical health as critical domains for assessment and intervention is important to capture those affected by trauma and target salient symptomatology. To ignore these problems as possible sequelae of trauma may be to ignore the problems most worrisome and prevalent to this population. The voices of Cambodian children and their families provide insight and direction to the international trauma-focused community invested in improving the wellbeing of Cambodian children.

Footnotes

Acknowledgements

The authors wish to express their sincere gratitude to Mr. Lun Lao, Ms. Phan Chanveasna, Ms. Mark Savy, Mr. Chandarey Vong, and all TPO staff for their support and guidance.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded in-part by a DePaul University internal research grant.

ORCID iD

Caleb J Figge

Caleb J Figge, PhD, is a clinical-child psychologist and a Fogarty global health research fellow at the Harvard TH Chan School of Public Health and Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania. Broadly, his research focuses on biopsychosocial outcomes of childhood adversity. His research aims to integrate local expressions of distress and health-seeking behaviors into assessment, intervention, and community program design in low- and middle-income countries.

Cecilia Martinez-Torteya, PhD, is a clinical psychologist and faculty member at Universidad de Monterrey and DePaul University. She studies the effects of early exposure to violence and risk and protective mechanisms that shape children's biopsychosocial outcomes in the face of traumatic stress.

Sopheap Taing, BA, is the Research, Monitoring, and Evaluation Coordinator for the Transcultural Psychosocial Organization (TPO) Cambodia. She is also actively involved in TPO’s fundraising activities, and supervises TPO’s Community Mental Health programs in the Siem Reap, Battambang, and Kampong Thom provinces. She obtained her BA in Psychology from the Royal University of Phnom Penh.

Chhim Sotheara, MD, PhD, MPM, is a senior consultant psychiatrist and Executive Director of the Transcultural Psychosocial Organization (TPO) Cambodia. Dr. Chhim has been providing mental health services to Cambodian people for the past 24 years with a special interest in trauma, transcultural psychiatry, and community mental health. He testified twice as a trauma expert for Khmer Rouge survivors at the Extraordinary Chambers in the Court of Cambodia.

Devon E Hinton, MD, PhD, is an anthropologist and psychiatrist, and an associate professor of psychiatry at Massachusetts General Hospital and in the Department of Global Health and Social Medicine, Harvard Medical School. He has researched in cross-cultural perspective idioms of distress, somatic symptoms, sleep paralysis, panic attacks, panic disorder, and PTSD, with a focus on Southeast Asian populations, particularly Cambodian and Vietnamese refugees, as well as Latino populations. He has written extensively on culturally sensitive CBT. He is fluent in several languages including Cambodian, Spanish, and Thai.

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